Lemon Bottle Consultation Form
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Email *
Name *
Date of Birth *
Gender *
Address *
Phone *
 Do you have a current condition requiring medical treatment? *
If yes, please detail
Are you currently receiving any treatment from a doctor or specialist? *
If yes, please detail
Do any of the following apply? *
Required
If any please explain
Do you, or have you ever had or take any of the following? Please select all that apply *
Required
If any please specify
Do you have any of the following in the area to be treated? *
Required
If any please specify
Are you or have you been, treated with any of the following? *
Required
If any please specify
Are you currently undergoing or have you previously had any of the following cosmetic treatments? *
Required
If any please specify
Do you wear any of the following? *
Required
If yes please specify
Are you 5 weeks pre/ post radiotherapy/ chemotherapy? If so please obtain medical consent *
Do you suffer from Epilepsy and have had a seizure within the last 2 years *
Have you ever had an allergic reaction to beauty treatments including injectables? *
If yes please specify
What kind of sun exposure do you get? *
Do you take regular exercise *
If yes please specify

Photographs

For insurance purposes, photographic documentation is required to keep as a record of your treatments. These photographs will be taken BEFORE, DURING and AFTER each procedure. If your consent is not given, the fat-dissolving treatments cannot be carried out.

I agree to photographic documentation of the treated area to be taken

 *

We would like to use your BEFORE, DURING & AFTER photographs for promotional purposes in social media & marketing material so that others may benefit from similar great results.

I consent to photographs taken before, during & after my treatment to be used for promotional purposes on social media and marketing material.

 *

Once you have read, understood, and accepted all sections of this consultation form, please complete the form by pressing the submit button to indicate everything is accurate and you have read all the information including the below declaration. You will then be required to come to our clinic for a consultation. Once this process has been completed, you may go away and consider the treatment before booking an appointment or proceed with treatment should you wish. Please ensure that you complete this consent form no less than 48 hours before your consultation appointment to give us the time to check it thoroughly. If you are concerned about a medical condition not listed on this form that may prevent you from having this treatment, please consult your Doctor/GP and provide a medical note to confirm that you are able to have the treatment. If this is necessary, please speak to us and organise it prior to your consultation appointment. We will require a physical hard copy of this letter to be stored on your file.

I fully understand that each person's body's and lifestyle are unique, therefore there are no guarantees about the success or longevity of this treatment.

 *

I declare that all the information I have given is, to the best of my knowledge, factual, relevant, and accurate. I understand that Essential Feeling will not be liable should I have knowingly given false information or withheld relevant details. I agree to inform Essential Feeling of any future changes to my health or contact details. I accept the risks and complications of the treatment and I understand that no guarantees are implied as to the outcome of the treatment. I agree that this constitutes full disclosure and that it supersedes any previous verbal and written disclosures. I certify that by submitting this button I have read and fully understood the entire informed consent form and that I have had sufficient time to ask questions and consider my treatment options.

 *
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